The risks of perinatal HIV transmission do not currently constitute grounds for morally criticizing the reproductive choices of particular infected women. A contextualized assessment of morally relevant factors might in some cases, however, justify judgments of reproductive irresponsibility. Although no women should be subject to any form of coercive pressure when making the decision to initiate or continue pregnancy, a "moral-education" model of nondirective counseling may be appropriate for women carrying HIV. Not even highly desirable, concerted public efforts to foster social justice will eliminate the ethical questions of whether these women should have children and how to counsel them.
PIP: Women infected with the human immunodeficiency virus (HIV) face a 20-30% risk of transmitting the virus perinatally and 25-30% of infected infants die before 2 years of age. The phenomenon of growing numbers of HIV-infected women in the US raises complex ethical questions about the individual rights of these women to reproductive freedom versus the societal goal of reducing the spread of acquired immunodeficiency syndrome (AIDS). Proposed is a model for assessment of the ethical dimensions of reproductive choices comprised of 4 elements: 1) the ability and willingness of parents to assume proper responsibility for the child, 2) the magnitude of the threatened harm, 3) the probability that harm will actually occur, and 4) the burden that parents must assume to avert the threatened harm. The risks of perinatal HIV infection lie on the margins of societal acceptability, yet careful moral scrutiny is called for on a case-by-case basis. Use of the above model would suggest justification for an asymptomatic women recently infected with HIV, married to an uninfected man who is committed to raising a child with the help of a large extended family, and opposed to abortion, to continue with her pregnancy. On the other hand, the model would not support continuation of pregnancy in the case of a homeless drug addict in poor health whose previous children have been placed in foster care. Also problematic is determination of the type of counseling that should be provided to HIV-positive women. Most appropriate at this time appears to be a moral education model of nondirective counseling aimed at providing support to a woman's choice after she has pondered all the ethical dilemmas posed by reproduction.